Provider Demographics
NPI:1467893867
Name:WHITE, RICHARD L (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:WHITE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8584 EDEN ISLES LN
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-6800
Mailing Address - Country:US
Mailing Address - Phone:321-795-6007
Mailing Address - Fax:877-787-5595
Practice Address - Street 1:234 WILLARD ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7984
Practice Address - Country:US
Practice Address - Phone:321-795-6007
Practice Address - Fax:877-787-5595
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 1171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant